Healthcare Provider Details

I. General information

NPI: 1760489629
Provider Name (Legal Business Name): MAIN STREET FAMILY PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S MAIN STREET
CHINA GROVE NC
28023
US

IV. Provider business mailing address

302 S MAIN STREET
CHINA GROVE NC
28023
US

V. Phone/Fax

Practice location:
  • Phone: 704-857-8769
  • Fax: 704-857-8779
Mailing address:
  • Phone: 704-857-8769
  • Fax: 704-857-8779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNC

VIII. Authorized Official

Name: ELIZABETH G HILL
Title or Position: OFFICE MANAGER
Credential:
Phone: 704-857-8769